Just the facts: A data-driven denial prevention program

Wednesday, October 20, 2021

Prevention is better than a cure, but that’s often easier said than done when it comes to denials. The challenge is two-fold: disagreements about accountability and responsibility and a lack of comprehensive data to understand root causes and trends early enough to act. These are complex problems that require organizationwide commitment—but the payoff more than makes the case.

Solving the root causes of denials requires consensus on responsibility but that’s hard to come by. Finger pointing is unfortunately common across revenue cycle departments, said Shannon Case, managing consultant at Baker Tilly. On the July 30 episode of The Revenue Integrity Show: A NAHRI Podcast, Case and Geneva Schlabach, co-founder and CEO of VISPA, shared tips and best practices for developing a data-driven denials prevention program and breaking the cycle of finger pointing in the revenue cycle.

“Especially when it comes to payer denials, nobody wants to take the blame for that,” Case said.

It’s natural for department leaders and individual staff members to feel defensive or shift blame, Schlabach said. To head that off, focus on the problems and not the people. Use data and change the conversation from determining who is right to understanding what is right. Emphasize the collaborative nature of denials prevention and the entire revenue cycle’s shared responsibility and well-being.

Collaboration needs to be more than just a buzzword, and one way to make it a reality is by sharing information.

“It’s easy to silo data to certain departments,” Schlabach said. “I would like to suggest that, what if that data was available across the board to everybody? Everyone from patient access to billing and coding to follow up, so that everyone is looking at the same problems through the same lens.”

When looking for solutions, it’s easy to consider only what’s right in front of you, she added. But by digging down to the root cause and fostering open, interdepartmental discussion, it’s possible to spot details and trends that would be lost at a higher level or if only one department reviewed the data.

The most useful data for this approach may also be the most overlooked, Case said. Common, routine data, such as 835s and 837s or claims rejected by bill scrubbers, are rich sources of insights on denials.

With the right data and the focus firmly on problematic processes rather than people, the next step is to address process breakdowns and barriers, Case explained. Review the tools staff members use across the revenue cycle. Some of these tools may have been cutting edge when they were first implemented but are now no longer up to the task. Look into workflows and whether departments are using workarounds to avoid following new or standardized processes. For example, patient access staff generally know they need to complete insurance verification and eligibility. However, some organizations face a high volume of denials that can be traced back to this step. Consider what processes and practices are preventing staff from ensuring a clean claim is issued and whether existing tools hinder more than they help.

Case and Schlabach capped off their discussion by sharing the following six best practices to building a successful denial prevention program:

  • Use technology to create a unified view of data and to track claims. Share across teams.
  • Drill down into details, create dashboards, and leverage reports to put everyone on the same page.
  • Identify process breakdowns and barriers on the front end. What is stopping staff from ensuring a clean claim?
  • Determine staff needs and common root causes of denials.
  • Establish new processes and policies to ensure clean claims and have zero tolerance for noncompliance.
  • Hold staff accountable. Halt the use of workaround in the revenue cycle.


Editor’s note: Listen to episodes of The Revenue Integrity Show here. Find more NAHRI resources on denials and denial prevention here.

Found in Categories: 
Denials and Appeals, Revenue Integrity